Micro Loan Application

DEBCO Micro Loan Application Package DeKalb Enterprise Business Corporation 150 E. Ponce De Leon Ave. Suite 400 Decatur, Georgia 30030 P 404.378.1899 F 404 377 8880 www.debco.org Welcome to the new DEBCO Micro Loan Application. In our effort to help improve the Application process for our customers, we have created Portible Document File (PDF) Fill-in forms. Its simple to use. Just place your cursor in the area where you would normally handwrite the information and click. Once you perform that simple menuver the cursor will begin blinking indicating that you can begin typing. Once you have completed the form, save it, print it, email it, do whatever you please. We hope you find using the PDF fill-in forms efficient and a time-saver. If you prefer to fill-in the documents by hand, simply print the Package and complete the document. Remember, you will need to sign several of the documents, so print out the saved document after you have filled-in the information and sign the various forms to complete the application. 2006 Dear Applicant: Thank you for your inquiry about the DEBCO Micro Loan Fund. We have been authorized by the U.S. Small Business Administration to make micro loans in the following counties; Clayton, Cobb, DeKalb, Fayette, Fulton, Gwinnett, Henry, Newton and Rockdale. The loan application and supporting schedules are included in the loan package available on our web site. When you have completed the application you may either submit it via mail or call our office to set up an appointment to submit or review your application. If you require assistance with preparing your business plan or other information required in the application, please contact the University of Georgia Small Business Development Center. A link to their site is on our site or you may call their Decatur Office at 404-371-7399 and they will direct you to the SBDC closest to you. Most for-profit small businesses operating in the counties listed above are eligible to apply. Day Care Centers are the only non-profit businesses that are eligible for this program. Please refer to the micro loan package for detailed information on the eligible use of proceeds for micro loans. If you have any questions about our micro loan program or if you would like to schedule an appointment, please feel free to give us a call. Sincerely, Charles Blackmon Executive Director charles.blackmon@debco.org www.debco.org DEBCO SBA MICROLOAN PROGRAM FACT SHEET The DeKalb Enterprise Business Corporation is a SBA Intermediary Lender that has been selected to administer a Microloan Program in Cobb, Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, Newton, and Rockdale Counties, Georgia. ELIGIBLE BORROWERS Any For-Profit business with under $5.0 million in annual sales and fewer than 500 employees, and wholesalers under 100 may be eligible. Micro borrowers must provide a letter stating that they cannot get credit from other lending sources. ELIGIBLE USES OF LOAN PROCEEDS Working capital, purchase of inventory, supplies, furniture, fixtures, raw materials, machinery and equipment. Proceeds cannot be used to buy a building or refinance existing debt. MAXIMUM AMOUNT Loans are available from $1,500 (minimum) to $35,000 (maximum). The SBA guidelines encourage DEBCO to make loans of not more than $7,500, however; each application will be considered on the basis of the company’s unique financial needs. INELIBIBLE BORROWERS AND USES 1). Non-Profit organizations, 2). Consumer or marketing cooperatives, 3). Businesses dealing in; the creation, origination, expression or distribution of; ideas, values, thoughts, or opinions (i.e. magazines, newspapers, books, other media, etc.) are not eligible. 4). Specialty stores primarily engaged in selling products that promote or advocate ideas. Specialized delivery, distribution or transportation concerns limiting themselves to distribution of ineligible materials area not eligible. 5). Loans to refinance existing debt. RATES/TERMS If the microloan is $10,000 or less, DEBCO may charge up to 8.5% over the cost of funds. If the microloan is greater than $10,000 DEBCO may charge up to 7.75% over the cost of funds, (This would make the average rates about 10%). There is a $100 service charge and the borrower is required to pay any closing cost and normal filing fees. The repayment period will be determined on a case by case basis not to exceed six (6) years. COLLATERAL/SECURITY Collateral (or security) will be determined on a case by case basis, however; potential borrowers are informed that DEBCO is legally bound by the SBA to secure each loan with sufficient collateral. First lien on any asset purchased is required. Personal guarantees of the principal owners of the business are required (unless a d/b/a). TECHNICAL ASSISTANCE DEBCO offers technical assistance to all clients who participate in the program. Technical Assistance is designed to help micro entrepreneurs obtain any additional tools needed to operate their businesses successfully. MICROLOAN CHECKLIST The following items must be included with your application (All forms must be complete): • • • • • • Application pages 1 through 9 Schedule of Business Liabilities Estimated Projection and Forecast Statement of Personal History (SBA form 912) Personal Financial Statement (must be signed, must have SSN). Monthly Household Income and Expense Sheet The following items must be attached to your application: • • • Business Plan if a “Start-Up” (Business operation less than two years). Current Business Financial Statement (Balance Sheet and Profit and Loss Statement). Personal Tax Returns for the last two years (if a d/b/a be sure to include Schedule C). Business Tax Returns (if business is a Corporation, Partnership or other legal entity required to submit returns). • PROGRAM OVERVIEW The DeKalb Enterprise Business Corporation is a Small Business Assistance (SBA) Intermediary Lender selected to administer the Microloan Program in Clayton, Cobb, DeKalb, Gwinnett, Henry, Fayette, Fulton, Newton and Rockdale Counties. PROJECT ELIGIBILITY • Any business located within approved counties • Have under $5.0 million annual sales • Have fewer than 500 employees • Wholesalers with under 100 employees may be eligible • Provide letter stating inability to obtain credit from other lending sources PROJECT INELIGIBILITY • Non-profit organizations • Consumer and marketing cooperatives • Businesses that create, originate, express, or distribute ideas, values, thoughts or opinions • Specialty stores that primarily sell products that promote/advocate ideas, specialized delivery, distribution of transportation concerns • Loans to refinance existing debt USE OF PROCEEDS • Working capital • Purchase of inventory • Supplies • Furniture or fixtures • Raw materials • Machinery and equipment RATES/TERMS • Current interest rate is 10% APR, and repayment is on a case by case basis, not to exceed 6 years IF the microloan is $10,000 or less, DEBCO may charge up to 7.75% over the cost of funds, making the rate about 10% • You pay closing costs and normal filing fees, which varies per loan Loans are processed on a first-come, first-served basis, and rates and terms are COLLATERAL/SECURITY • Collateral or security is on a case by case basis. DEBCO is legally bound by the SBA to secure each loan with sufficient collateral • First lien on any asset purchased is required • Personal guarantees of the principal owners of the business TECHNICAL ASSISTANCE • DEBCO offers technical assistance designed to help clients obtain additional tools to operate their business successfully LOAN APPLICATION CRITERIA PERSONAL INFORMATION Get Started with our Simple Application Your Name (First, MI, Last) Social Security Number Address City/State County Zip Phone Fax E-mail ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ Get Started with our Simple Application: Business Information Name of Business Tax ID Address City/State County ___________________________ ___________________________ ___________________________ ______________ ____________ _____________ Zip __________ No (circle one) Same as Personal Address? Yes Phone _____________________________________ Cell Phone __________________________________ Fax ________________________________________ E-mail _____________________________________ Website ____________________________________ Describe your business (use up to 5 words) ___________________________________________ Are you starting this business from the ground up? Yes No (circle one) If you are currently in business, how long? Years___ Months___ Are you purchasing an existing business? Yes No (circle one) OWNERSHIP INFORMATION Ownership (answer all that apply) Is the business owned and controlled by: Minority(s) Female(s) Veteran(s) Handicap Person(s) Other percent Is the business located in a: Rural Area Business Revitalization District Historic District Low Income Neighborhood Don’t Know Does your business engage in: Exporting 8(a) Contracting (circle one) yes no (circle one) yes no (circle one) yes no (circle one) yes no (circle one) yes no (circle one) yes no (circle one) yes no _______ percent _______ percent _______ percent _______ percent _______ percent Other ____________________________________________________ LOAN SUMMARY How much of your own money are you putting into the transaction? How much money do you need to borrow through DEBCO? Real Estate Raw Land Land & Building Construction $__________ $__________ $__________ Operations Equipment Furniture/Fixtures Inventory Pay-off Payables Pay-off Other Loans Operations Cash Other Operations Various Buy a Business $__________ $__________ $__________ Operations Total $__________ $___________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ Renovation/Rehabilitation $__________ Other Real Estate Real Estate Total $__________ $__________ Leasehold Improvements Research & Development Professional Fees Deposits Other Various Various Total Grand Total $__________ $_________ $__________ $__________ $__________ COLLATERAL INFORMATION Description of Collateral _______________________________ ___________________________________________________ ____________________________________________________ In addition to assets being purchased with this loan money, what other assets may we use to secure this loan? ____________________________________________________ ____________________________________________________ Real Estate $____________ (value after other debt is subtracted from today’s market value) Business Assets (value after other debt) Personal Property (value after other debt) Other (value after other debt) I have no other assets to secure this loan. (circle one) Yes No Co-Signer (circle one) Yes No General Comments (up to 6 words) _________________________ ______________________________ __________________________ $____________ $____________ $____________ MANAGEMENT INFORMATION If you are starting this business from the ground up, have you worked in this type of business in the past? (circle one) Yes No If yes, how long? Do you have experience / training in this type of business? (circle one) Yes Is this is an existing business? (circle one) If yes, how long has it existed? Has it been profitable in the past? Is it profitable now? Are all taxes current? Are current financial statements available (within 90 days of this application)? Are historical statements available (within 90 days)? Years____ Months____ No Yes No Years____ Months____ (circle one) Yes No (circle one) Yes No (circle one) Yes No (circle one) Yes No (circle one) Yes No CREDIT HISTORY INFORMATION Credit History (all owners of the company): If you are unsure of your credit history, you can obtain a free credit report by calling: Experian at (888) 3973742 or Equifax at (800) 685-1111 or you can order online at www.econsumer.equifax.com. How do you characterize the credit record of the company and its owners? (circle one) Excellent Good Fair Poor Comments (up to 6 words) ____________________________________ Have any owners of the company been involved in bankruptcy proceedings? (circle one) Yes Are any owners of the company under indictment or parole or probation? (circle one) Yes Have any owners of the company ever been convicted of a criminal offense? (circle one) Yes Are all owners US citizens? (circle one) Yes No No No No If no, give alien registration numbers and type of visas: _____________ Can we check the credit of the company and/or the owners of the company? (circle one) Yes No OTHER INFORMATION How did you find out about DEBCO? I was referred by: Searching the internet: __________________________ Advertising: ___________________________________ Direct Mail: ___________________________________ Other: _______________________________________ What’s the best way to contact you? (circle one) Phone Fax Cell Phone Email Mail What’s the best time to contact you? _______________ Other Essential Information We Will Need: 1. Current Financial Statement (within 90 days) 2. Business Tax Returns (3 years) and/or Year End Financial Statement 3. Projected Income Statement (12 months) 4. Personal Financial Statement: print out form from http://www.sba.gov/sbaforms/sba413.pdf 5. Business Plan if a “Start-Up” Transaction CERTIFICATIONS, RELEASES AND DISCLAIMERS I/We understand that other items will be required to obtain a final decision on this application. These items will be requested by a loan officer. I/We assure you that all the information furnished in this application is complete and correct. You may verify any of this information. I understand that from time to time, you may receive information from others and you will answer questions and requests from others seeking credit experience information about accounts. I/We understand I/We may apply for credit in my name alone without my spouse or any other person, regardless of my sex or marital status. Credit Check Authorization I/We authorize DEBCO and SBA to contact credit reporting agencies (Equifax, Dun and Bradstreet, etc...) and creditors with regard to the status of any past or outstanding debt, or such other credit information that such agencies normally hold available for credit worthiness evaluation at present or at any time in the future for the purpose of making or monitoring a loan. Policy Regarding Fees Some SBA loan programs require fees for service. After the preliminary review stage has been completed and eligibility determined, fees will be fully disclosed. Authorization To Release Information This is to certify that I/We, as an applicant for a loan with DEBCO, do hereby authorize the release of any and all information to the Small Business Administration from whomever they deem it necessary to make such a request. Such information will include, but will not be limited to: credit history, criminal history records, military records, former employer records and educational records or transcripts. I/We also release all persons from any liability, which results from furnishing said information to the DEBCO and the Small Business Administration. Further, I/We authorized DEBCO and the Small Business Administration to copy or otherwise reproduce this original document and to let such copied or otherwise reproduced copies act as the original instrument. The original document is to be retained on file with the Small Business Administration for no less than two years. I/We have read and accept the above certifications and disclaimers: _________________________________________________________ Signature Date _________________________________________________________ Signature Date ATTACHMENT “A” SAMPLE BUSINESS PLAN A business plan is used to introduce your business and/or project to prospective lenders, in this case the participating bank and the DEBCO Loan Review Committee. It will show us how well your proposal/project has been thought out. The length and sequence of the contents of a business plan will vary depending on the type and complexity of the project. The sample business plan format listed below may be modified, but it is suggested that all of the components should be addressed if relevant. Overall length of 3-5 pages is sufficient (excluding the financial plan portion). Company Overview --- Name and Location --- Legal Structure --- Principal Owners/Management Team (summarize individual qualifications) --- History of the Business --- Company Direction Products or Services Offered --- Describe Product(s) or Type(s) of Service(s) --- Describe Materials and Supply Source --- Quality and Cost of Product or Service Market Information/Analysis --- Describe/Define the Market for Your Product or Service --- Profile Existing and Potential Customers --- Describe Your Competition --- Summarize Advantages of Your Product or Service over the Competition Advertising and Distribution --- Methods of Advertising and Promotion --- Sales Strategy --- Pricing Policy --- Distribution Channels --- Customer Service Facilities --- Location --- Size and Zoning --- Age and Condition Financial Plan ( Application requires two years financial statements and current interim statement, plus two years forecast). You may require assistance from other sources in preparing your business plan. The University of Georgia Small Business Development Center/ DeKalb Area Office (404-371-7399) is available to assist and advise you in this process. Monthly Household Income and Expense Sheet Name INCOME Money you receive Month/Year EXPENSES Money you spend, including self-established savings goals. GROSS SALARY, WAGES $ RENT in rent Include utility payments if automatically included $ MINUS DEDUCTIONS health insurance, etc. Federal and state income tax, FICA, Social Security, MORTGAGE PAYMENTS property tax and Include - $ $ $ insurance if automatically included in payment $ TAKE-HOME PAY OTHER GROSS SALARY, WAGES IN HOUSEHOLD MINUS DEDUCTIONS TAKE-HOME PAY COMMISSIONS, TIPS, BONUSES NET PROFIT FROM BUSINESS, FARM, TRADE, PROFESSION INTEREST OR DIVIDENDS FROM SAVINGS, STOCKS, BONDS, OTHER SECURITIES, NOTES NET PROFIT FROM SALE OF ASSETS NET PROFIT FROM RENTAL PROPERTY PAYMENTS FROM OTHERS support Alimony, child 0 OTHER REAL ESTATE homeowners association fees Second mortgage, home improvement (if secured by home), vacation home, storage rental, $ Gardening, HOUSEHOLD MAINTENANCE, REPAIR - $ $ $ FOOD $ Groceries, nonfood items in supermarket bill housecleaning, appliance repairs (material, labor) $ 0 UTILITIES Gas, electricity, heating, fuel, phone, water, cable TV, garbage $ $ TRANSPORTATION Car operating expenses (gas, oil, repairs, servicing), parking, public transportation $ CREDIT, CHARGE ACCOUNTS Payments for charge $ $ $ $ accounts, credit cards, personal lines of credit $ Payments made INSTALLMENT CONTRACT PAYMENTS vehicle, mobile home, furniture, etc. at regular intervals over specific time periods for purchase of $ INSURANCE Real property (fire, liability, theft, etc., if not included in mortgage payments), personal property (homeowners, renters, auto), life hearth, other $ REFUNDS, REBATES CASH GIFTS SOCIAL SECURITY BENEFITS IRA’s, SEPS, KEOGHS PENSIONS, ANNUITIES VETERANS BENEFITS UNEMPLOYMENT BENEFITS DISABILITY BENEFITS LIFE INSURANCE BENEFITS INCOME FROM TRUSTS ROYALTIES, RESIDUALS OTHER INCOME $ INCOME TAXES $ $ $ $ $ $ SELF-IMPROVEMENT, EDUCATIONBooks, magazines, $ $ RECREATION, ENTERTAINMENT $ $ sports, vacations, weekends, parties Restaurants, movies, newspapers, seminars, lessons, tuition, room and board away from home to taxes withheld Federal and state taxes due in addition $ If not part of mortgage payment PROPERTY TAXES OTHER TAXES $ $ $ Gift or estate taxes, for example Alimony, child support Clothing, laundry, barber, PAYMENTS TO OTHERS PERSONAL MAINTENANCE beauty salon, health and beauty products $ $ $ SAVINGS Savings accounts, Christmas Clubs, time deposits, U. S. Savings Bonds, and so on $ $ PERSONAL PROPERTY LEASE PAYMENTS Auto, furniture, equipment $ Church, charities, other TOTAL INCOME $ 0 0 0 REGULAR CONTRIBUTIONS DUES $ $ Union, club, and other memberships TOTAL INCOME MINUS TOTAL EXPENSES - $ $ CHILD CARE babysitter Day care, nursery school, housekeeper, $ $ $ MEDICAL, DENTAL Drugs and treatments not covered by insurance Also include transportation costs OTHER EXPENSES DISCRETIONARY INCOME $ 0 TOTAL EXPENSES $ 0 OMB APPROVAL NO. 3245-0188 EXPIRATION DATE:11/30/2004 PERSONAL FINANCIAL STATEMENT As of , U.S. SMALL BUSINESS ADMINISTRATION Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock, or (4) any person or entity providing a guaranty on the loan. Name Residence Address City, State, & Zip Code Business Name of Applicant/Borrower ASSETS Cash on hand & in Banks Savings Accounts IRA or Other Retirement Account Accounts & Notes Receivable Life Insurance-Cash Surrender Value Only (Complete Section 8) Stocks and Bonds (Describe in Section 3) Real Estate (Describe in Section 4) Automobile-Present Value Other Personal Property (Describe in Section 5) Other Assets (Describe in Section 5) Total Section 1. Source of Income $ $ $ $ Salary Net Investment Income Real Estate Income Other Income (Describe below)* Description of Other Income in Section 1. $ $ $ $ $ $ $ $ $ $ (Omit Cents) LIABILITIES Accounts Payable Notes Payable to Banks and Others (Describe in Section 2) Installment Account (Auto) Mo. Payments $ Installment Account (Other) Mo. Payments $ Loan on Life Insurance Mortgages on Real Estate (Describe in Section 4) Unpaid Taxes (Describe in Section 6) Other Liabilities (Describe in Section 7) Total Liabilities Net Worth Total Contingent Liabilities As Endorser or Co-Maker Legal Claims & Judgments Provision for Federal Income Tax Other Special Debt $ $ $ $ $ $ $ $ $ $ $ $ $ (Omit Cents) Business Phone Residence Phone 0 $ 0 $0 $ 0 *Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income. Section 2. Notes Payable to Banks and Others. Name and Address of Noteholder(s) (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.) Original Balance Current Balance Payment Amount Frequency (monthly,etc.) How Secured or Endorsed Type of Collateral SBA Form 413 (3-00) Previous Editions Obsolete This form was electronically produced by Elite Federal Forms, Inc. (tumble) Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed). Market Value Date of Number of Shares Name of Securities Cost Total Value Quotation/Exchange Quotation/Exchange Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed.) Property A Property B Property C Type of Property Address Date Purchased Original Cost Present Market Value Name & Address of Mortgage Holder Mortgage Account Number Mortgage Balance Amount of Payment per Month/Year Status of Mortgage Section 5. Other Personal Property and Other Assets. (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency) Section 6. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.) Section 7. Other Liabilities. (Describe in detail.) Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries) I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001). Signature: Signature: PLEASE NOTE: Date: Date: Social Security Number: Social Security Number: The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this estimate or any other aspect of this information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance Officer, Paper Reduction Project (3245-0188), Office of Management and Budget, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB. ATTACHMENT “D” ESTIMATED PROJECTION AND FORECAST YEAR 1 GROSS RECEIPTS LESS: COST OF GOODS SOLD GROSS PROFIT LESS: EXPENSES Officers/Owners Salaries Employee Wages Employer Taxes (FICA, Unemployment, etc.) Profession Services (legal, accounting, etc.) Advertising Rent Depreciation Supplies Telephone Utilities Interest Maintenance & Repairs Taxes Insurance Reserve for Bad Debts Transportation Other: (specify) $0 Total Expenses Net Profit Before Taxes Less: Income Taxes Net Profit After Taxes Less: Owners/Partners Withdrawal or Dividends Net Profit Remaining For Debt Repayment NOTE: ATTACH A NARRATIVE EXPLAINING BASIS FOR ALL FIGURES $0 $0 $0 $0 Return Executed Copies 1, 2, and 3 to SBA OMB APPROVAL NO.3245-0178 Expiration Date:9/30/2006 Please Read Carefully - Print or Type United States of America SMALL BUSINESS ADMINISTRATION STATEMENT OF PERSONAL HISTORY Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) Each member of the small business or the development company requesting assistance must submit this form in TRIPLICATE for filing with the SBA application. This form must be filled out and submitted by: 1. By the proprietor, if a sole proprietorship. 2. By each partner, if a partnership. 3. By each officer, director, and additionally by each holder of 20% or more of the ownership stock, if a corporation, limited liability company, or a development company. SBA District/Disaster Area Office Amount Applied for (when applicable) File No. (if known) 1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial only, indicate initial.) List all former names used, and dates each name was used. Use separate sheet if necessary. First Middle Last 2. Give the percentage of ownership or stocked owned Social Security No. or to be owned in the small business or the development company 3. Date of Birth (Month, day, and year) 4. Place of Birth: (City & State or Foreign Country) Name and Address of participating lender or surety co. (when applicable and kno wn) 5. U.S. Citizen? YES NO If No, are you a Lawful NO YES Permanent resident alien: If non- U.S. citizen provide alien registration number: Most recent prior address (omit if over 10 years ago): From: To: Address: 6. Present residence address: From: To: Address: Home Telephone No. (Include A/C): Business Telephone No. (Include A/C): PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION. IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED COMPLETELY. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED. IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY OTHER PERTINENT INFORMATION. 7. Are you presently under indictment, on parole or probation? Yes No (If yes, indicate date parole or probation is to expire.) 8. Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been dismissed, discharged, or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.) Yes No 9. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probati on, including adjudication withheld pending probation, for any criminal offense other than a minor vehicle violation? Yes No 10. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, and the Small Business Investment Act. CAUTION: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan, surety bond, or other program participation. A false statement is punishable under 18 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000. Signature Title Date Agency Use Only 11. Fingerprints Waived Fingerprints Required Date Sent to OIG 12. Date Date Approving Authority Approving Authority 13. Cleared for Processing Request a Character Evaluation Date Approving Authority Date Approving Authority (Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.) PLEASE NOTE: The estimated burden for completing this form is 15 minutes per re sponse. You are not required to respond to any collection of information un less it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval 3245-0178. PLEASE DO NOT SEND FORMS TO OMB. SBA 912 (10-03) SOP 5010.4 Previous Edition Obsolete This form was electronically produced by Elite Federal Forms, Inc. PERSONAL HISTORY STATEMENT (attachment E – Page 2) College or Technical Training Name and Location 1 Comments: 2 Comments: 3 Comments: Dates Attended From To Major Degree or Certificate WORK EXPERIENCE List chronologically, beginning with present employment. 1. Name of Company Full Address: From: Title: 2. Name of Company Full Address: From: Title: 3 Name of Company Full Address: From: Title: 4. Name of Company Full Address: From: Title: To: Duties: To: Duties: To: Duties: To: Duties: __________________________________________ Percentage of business owned NOTICES REQUIRED BY LAW The following is a brief summary of the laws applicable to this solicitation of information. Paperwork Reduction Act (44 U.S.C. Chapter 35) SBA is collecting the information on this form to make a character and credit eligibility decision to fund or deny you a loan or other form of assistance. The information is required in order for SBA to have sufficient information to determine whether to provide you with the requested assistance. The information collected may be checked against criminal history indices of the Federal Bureau of Investigation. Privacy Act (5 U.S.C. § 552a) Any person can request to see or get copies of any personal information that SBA has in his or her file, when that file is retrievable by individual identifiers, such as name or social security numbers. Requests for information about another party may be denied unless SBA has the written permission of the individual to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to make a character determination. In determining whether an individual is of good character, SBA considers the person's integrity, candor, and disposition toward criminal actions. In making loans pursuant to section 7(a)(6) the Small Business Act (the Act), 15 USC § 636 (a)(6), SBA is required to have reasonable assurance that the loan is of sound value and will be repaid or that it is in the best interest of the Government to grant the assistance requested. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC § 636(a)(1)(B). Further, for all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate or will violate the Act or the Small Business Investment Act,15 USC §§ 634(b)(11) and 687b(a). For these purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character determination and to distinguish you from other individuals with the same or similar name or other personal identifier. When this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, SBA may refer it to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations. See 56 Fed. Reg. 8020 (1991) for other published routine uses. Applicant’s Name _______________________ SUGGESTED FORMAT (Notes, Mortgages and Accounts Payable) OMB No. 3245-0017 SCHEDULE OF LIABILITIES Date of Schedule____________________ Original amount Original date Current balance Current or delinquent? Maturity date Payment amount (Month- Year) How Secured Name of Creditor _________________________________________ Signed This form is provided for your convenience in responding to filing requirements in item 2 on the application, SBA Form 5. You may use your own form if you prefer. The information contained in this schedule is a supplement to your balance sheet and should balance to the liabilities presented on that form. _________________________________________ Title SBA Form 2202 (11-01) THE DEKALB ENTERPRISE BUSINESS CORPORATION, INC. HOLD HARMLESS AGREEMENT THIS AGREEMENT made this day of , 20 , by and between the DeKalb Enterprise Business Corporation, Inc. (hereinafter referred to as “DEBCO”) and (hereinafter referred to as “Applicant”). In consideration of the mutual promises hereinafter set forth, it is agreed as follows: 1. ASSISTANCE TO BE PROVIDED BY DEBCO DEBCO shall review the information provided by the applicant as a part of the applicants application for financial assistance. The application and supporting data will be reviewed by DEBCO staff to determine the applications compliance with DEBCO’s Financial Assistance Policy. DEBCO staff shall make recommendation for approval or declination to the DEBCO Loan Committee based on staffs evaluation of the application. The Loan Committee shall have the final authority to approve or decline the application of the Applicant . Applicant understands and agrees that DEBCO is under no obligation to approve or extend a loan to Applicant. When appropriate the staff will attempt to identify a Bank or other Financial Entity who will participate in the Applicant’s request for funding as required by the DEBCO Financial Assistance Policy. 2. COMPENSATION TO DEBCO FOR PROPOSED ASSISTANCE Revolving Loan Fund: A one time processing fee of 1% of the loan amount requested or $250, whichever is greater, payable in the following manner: $50.00 upon receipt of the application, 50% of the remainder prior to submission to the loan committee and the remaining fee due prior to closing. Micro Loan Fund : A one time processing fee of $100.00 regardless of the amount borrowed . Applicant is responsible for all closing costs for either loan fund . 3. COOPERATION OF APPLICANT Applicant shall promptly provide in full any and all information and/or documents requested by DEBCO. Applicant further is advised and agrees to accept ongoing monitoring activities by DEBCO. ______ Initials 4. DEBCO’s TERMINATION RIGHTS DEBCO expressly reserves the unconditional right to terminate this agreement in whole or in part at any time upon written notice to Applicant. 5. GENERAL RELEASE BY APPLICANT Applicant hereby fully and forever releases and discharges DEBCO, its officers, directors, employees, agents, servants, affiliates, subcontractors and/or subsidiary companies (hereinafter referred to individually and collectively as “DEBCO, ET AL.”) from any and all damages, claims, demands and causes of action which Applicant has had, now has, or might have in the future against DEBCO, ET AL. by reason of any occurrences, specifically included, without limitations, damages, injuries and losses of any type or manner whatsoever arising from any services of DEBCO, ET AL. performed and/or not performed. This is intended as a full and complete release of any and all damages, demands, claims and causes of action Applicant has had, may have, or might expect to have based on any occurrence to date, and further, of any occurrence which may occur on and/or after the date of this agreement, specifically including, without limitations, any damages, the effects and results of any such damages whether expected or unexpected, and whether if it were known by Applicant might have materially affected this agreement with DEBCO, ET AL. 6. INDEMNIFICATION OF DEBCO, ET AL. As a condition precedent and a covenant to any obligation of DEBCO in accordance with this Agreement, and any supplemental agreements, if any, whether oral or written, Applicant agrees to and warrants that it will indemnify and hold DEBCO ET AL wholly harmless from any and all damages, claims, demands, and causes of action by any person, or persons arising from or relating to any services of DEBCO, ET AL. performed, partially performed and/or not performed. 7. ASSUMED DEFENSES OF DEBCO, ET AL. As a condition precedent and a covenant to any obligations of DEBCO, ET AL. in accordance with this Agreement and supplemental agreements hereto, if any, whether oral or written, Applicant agrees to and warrants that it will defend DEBCO, ET AL. at its own expense, specifically including, without limitations, attorney’s fees, court costs, expert fees, and investigation fees and expenses, against any and all damages, claims, demands, and causes of action made upon DEBCO, ET AL. performed and/or not performed in accordance with, or related to this Agreement, if any, whether oral or written, and any and all other relationships, agreements and/or activities by and between Applicant and DEBCO, ET AL. ______Initials 8. ENTIRE AGREEMENT AND PARTIES IN INTEREST This Agreement embodies the entire agreement and understanding by and between Applicant and DEBCO, ET AL. and supersedes all prior agreements and understandings relating to the subject matter hereof. All of the terms and provisions of this Agreement shall be binding upon and inure to the benefit of and be enforceable by the respective successors and assigns of the parties hereof. 9. PARTIAL INVALIDITY AND WAIVER OF BREACH If any terms, provision, covenant or condition of this Agreement is held by a court of competent jurisdiction to be invalid, void, inapplicable or unenforceable, the remainder of the terms, provisions, covenants, and conditions and other applications of this Agreement shall in no manner whatsoever be affected, impaired or invalidated. The waiver of any provision of this Agreement shall not operate or be construed as a waiver of any subsequent breach. 10. FREEDOM OF INFORMATION ACT PROVISION The information provided in accordance with the aforementioned terms will be treated as privileged information and will not be disclosed to third parties without the consent of the information provider, with the exception of information DEBCO is required to provided to the U. S. Department of Housing and Urban Development (HUD) , U.S. Small Business Administration , or DeKalb County Government . IN AGREEMENT WITH THE ABOVE, the parties hereto have executed this Agreement on the date first above written. Applicant : By: _______________________________________________ Address: Tax I.D.# or SSN. : THE DEKALB ENTERPRISE BUSINESS CORPORATION, INC. By: _______________________________________________ ___________ Date ___________ Date “GUIDELINES” FOR PREPARING PERSONAL FINANCIAL STATEMENTS All loan applications require the submission of personal financial statements on all principals (borrowers). Personal financial statements relate only to personal assets and liabilities; therefore, business assets and liabilities are excluded. These guidelines should be helpful in preparing your personal financial statements within the application you have requested of DEBCO. 1. Select the most recent period on which financial data will be based. The selection of an end-of-month period is deemed appropriate. Statements should be no more than 30 days old. 2. Note that the detailed information listed in sections 2-8 of the personal financial statement must be completed before completing the asset/liability/net worth sections. COMPILATION OF DATA ASSETS: In general terms this refers to the properties owned by an individual (excluding business assets) at a particular period in time. A. Cash on Hand and in Banks: This represents personal checking account balances plus any cash or checks not yet deposited. Such information is generally obtained from monthly bank statements. If you have several accounts, compile the amounts on a separate schedule and enter the total on the financial statement form. B. Savings Accounts: This represents savings account balances plus certificates of deposit (CDs). C. IRA: This includes funds in Individual Retirement Accounts; 401Ks, Teachers Retirements, Keogh Plans, and SEPs. D. Accounts and Notes Receivable: Accounts receivables represent amounts due from individuals or businesses arising from performance of business related services. A note receivable is an unconditional written promise by one party to another to pay a certain sum of money at a specific time period, usually over one year (i.e. private loan). continued F. Other Stocks and Bond: This represents the cost and market value of both listed and unlisted stocks and bonds held. Information relating to the cost and value of stocks and bonds could be obtained from any local stockbroker (e.g., Merrill Lynch) or the business section of the local newspaper. Note: Both costs and market values of stocks are required on the personal financial statement (see Section III). G. Real Estate: This represents the market value of all real estate owned by an individual (i.e. private residence, land, etc.). Market value may be defined as the price at which a prudent buyer would pay and a prudent seller would accept can be determined from recent appraisals, asking prices for similar properties or your county tax assessor’s office. H. Automobile: This represents the book value [sometimes referred to as the blue book value, (BBV)] of all automobiles owned. Information relating to the BBV of an automobile may be obtained from an automobile dealership or bank that finances automobile purchases. I. Other Personal Property: This represents personal property other than automobiles. These include items such as investment in a sole proprietorship or partnership, household goods and appliances, furniture, jewelry, art, and other collectibles. J. Other Assets: This represents all other assets other than those mentioned above. Such assets may include prepaid items and other advance payments such as deposits for personal services (i.e. telephone or utilities deposits). LIABILITIES: This represents all non-business related amounts owed to individuals or establishments. K. Accounts Payable: This represents amounts due to individuals or establishments arising from the performance of non-business related services. L. Notes Payable to Banks and Others: This represents the principal amount due on bank loans as of the financial statement date. These include all notes other than real estate and automobiles. Balance information may be obtained from the original note and/or monthly loan statements (see section II). M. Installment Accounts: This represents the balance due on an automobile loan. All information relating to automobile loans may be obtained directly from the lending company. Ask for the original loan amount and monthly payment amounts. continued N. Installment Accounts (other): This represents the balance due on established lines of credit, notably charge accounts (Visa, MasterCard, American Express, J.C. Penney, etc.). All information relating to account balances may be obtained from monthly statements. O. Loans on Life Insurance: This represents the balance due on any loans made against the cash value of life insurance. P. Mortgages on Real Estate: This represents the principal balance due on any mortgages payable on real estate. Balances can be obtained from the year-end statements or from your mortgage lender. Q. Unpaid Taxes: This represents amounts due to either the Internal Revenue Service, state, or local tax agencies. R. Other Liabilities: This represents amounts due on liabilities other than those listed above. S. Net worth: This represents the difference between total assets and total liabilities. DeKalb Enterprise Business Corporation AUTHORIZATION TO RELEASE INFORMATION This is to certify that I, , as an applicant for a loan with the DeKalb Enterprise Business Corporation, do hereby authorize the release of any and all information to the DeKalb Enterprise Business Corporation from whomever they deem it necessary to make such a request. Such information will include, but will not be limited to: credit history, criminal history records, military records, former employer records and educational records or transcripts. I also release all persons from any liability which results from furnishing said information to the DeKalb Enterprise Business Corporation to copy or otherwise reproduce this original document and to let such copied or otherwise reproduced copy act as the original instrument. The original document is to be retained on file with the DeKalb Enterprise Business Corporation for no less than two years. Name (PRINTED) Address City SSN Employer Employer address City State Zip State Zip ________ Date of Birth (mm/dd/yy) (Signature) For Office Use Only EDS _ (initials) (Date) Personal Business Both Prior Approval Reset Form